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Nursing progress note 7 Hyperbili #1 O: Blood cultures neg to date. Antibiotics to be d/c'd after next ampicillen dose. A: No signs or symptoms of sepsis. P: D/c meds. #2 O: Baby remains orally intubated in 21% O2, 15/5 X's 12. Breath sounds equal & clear with mild IC/SC retractions. Suctioned for sm wh ETT & sm clear. Remains on caffeine. No A's or B's. A: Stable on vent in room air. P: Plan to extubate to NP CPAP. Cont to assess. #3 O: Remains NPO. Presently receiving 100cc/k/d. Total fluids to be inc to 120cc/k/d when new TPN arrives. IL to be started. Fluid infusing thru DUV. DS 72. Abd soft with inaudible bowel sounds. UOP since midnoc is 7.1cc/k/h. A: Receiving fluids as ordered. P: Cont to assess. #4 O: Soft murmur heard X's 2. Pulses equal & not bounding. BP stable. A: Murmur prob PDA. P: Cont to assess for signs of compromise. #5 O: Remains on warmer. Nested in sheepskin. Sucks intermittently on pacifier. Irritable with cares but calms with nesting. A: AGA. P: Cont to assess. #6 O: Parents visited at 10AM & Dad visited briefly at 1PM. A: Parents seem more at ease & are pleased with baby's progress. P: Support. Family meeting when Mom is discharged. #7 O: Single phototherapy started at 11AM. Eye patches on. A: Hyperbili of prematurity. p; Cont to assess. Bili ordered for midnoc. REVISIONS TO PATHWAY: 7 Hyperbili; added Start date: [**2141-7-5**]

Overall Neutral Note

NPN NPN#1 O= remains on ampi & gent as ordered, gent's time changed to q36hrs after pre gent of 1.2, post 7.6, blood cx remain - to date, active with cares/ tone hypotonic..appropriate for GA A= r/o sepsis P= cont to assess & monitor for S&S of sepsis NPN#2 O= BW 654gms, current wt on newly applied bedscale of 490gms, TF ^ 240cc/kg/d after 2200 lytes of 150/ 6.0/ 119/19...next set of lytes due to be drawn at 0600, PND5 at 75cc/kg/d via primary port of DUV, secondary port with D5% with .5uheparin/cc infusing well and UAC with .5NS with .5uheparin/cc at KVO/ 1.0cc/hr..both to equal remaining fluids at 165cc/kg/d..DS stable x2 at 99, abd exam flat/ soft -BS, -loops, no stool uo= 7.7cc/kg/hr overnight spilling tr. prot./ph 7.0/ lg-mod heme.. A=electrolyte imbalance with continued hypernatremia P=cont with strict I&O, close monitoring of lytes q8hr as ordered, daily wts ? [**Hospital1 55**], NPN#3 O= placed on bedscale..remains on open warmer on servo with Temp 98.8-98.7.. temp sensitive when plastic tent covering removed for cares..using warming lights with cares, hypotonic, MAE, nested in sheepskin with gel pad underneath,AF soft & flat, overidding sutures ,eyes remain fused, Fntanyl given x1 for agitation with good effect, cont with q6hr clustered cares A= fragile infant/ temp sensitive P= cont to assess & support dev needs/ q6hr cares, assess pain/ stress..Fentanyl prn as ordered NPN#5 O= no murmer heard, received third/ last dose of Indocin as ordered, HR mostly 140's-150's, pink & well perfused, good cap refill 2-3sec, pulses equal nonbounding, active precordium/- [**Location (un) 129**] pulse, remains off Dopa since 1100 yesterday with MAP's mostly low-mid 30's ( see flow sheet), pulse press. 18-22 pts., plan to draw am Hct/ plt.. A= remains off Dopa, no murmer heard P=cont to monitor closely,want Maps>28..assess need for Dopa, monitor for S&S of PDA, follow labs NPN#6 O= parents up x3 with infant's uncle/ grandmother..updated at bedside, quietly talking to [**Known lastname 722**]/ teary eyed at times

Overall Neutral Note

ADDENDUM NPN#6 O= parents in x1 overnight..updated at bedside, mom pumping in room, both softly talking to [**Known lastname 722**] and appear very supportive of one another, they are contiuing to stay next store at Best Western Hotel to be close to son..Tel # in front of chart A=appropriately concerned parents continuing to grieve loss of twinP= cont to update & support NPN#7 O= skin remains fragile, tegaderm intact over elbows/ kness, aquaphor oint applied x1,mult sm bruises..esp left upper arm/ head, sm abrasions on both feet r/t probe application, right ear abrasion dry at left OTA..skin intact no open weepy areas noted A= fragile skin P=cont with meticulous inspection/ care of skin NPN#8 O= remains under single spot light phototherapy with eye patches draped over eyes.am bili pnd A= hyperbili P= cont per plan

Overall Neutral Note

ADDENDUM NPN#6 ( cont.) parents staying in family room on [**Location (un) 1006**]..tel # in front of chart..plan to move to nearby hotel today..mom pumping..A=lovely appropriately devastated new parents/ grieving loss of twin P=cont to teach/ update/ support NPN#7 O= infant with mult bruising / skin although reddened in areas..intact/ sm dry abrasions of feet/ ankles r/t oximeter probe/ tegaderm intact over kness/ elbows..aquaphor oint prn/ A= very fragile skin P= cont to closely monitor skin's integrity NPN#8 O= remains under single spot light phototherapy with eye patches in place, mult bruising..A= hyperbili P= will obtain am bili with lab work/ max skin exposure to lights NPN#4 O= received on SIMV on settings of 20/5 x30 FIO2 mostly 30% ( ^ with cares), ABG at 2130 7.21/57..PIP ^ to 22 follow up ABG at 0130 7.27/ 44 no changes, LS clear with IC/SCR,sxn'd x1 at begining of shift for old/ rust secretions via ETT but last sxn no blood noted/ only white secretions, infant cont to breath with vent only, A= unable to wean s/p pul hemorrhage P=cont to monitor ABG's as ordered , assess for bloody ET secretions, follow closely

Overall Neutral Note

NICU Nursing Admission Note O: Baby boy [**Known lastname 1626**] was admitted to the NICU from L&D after being born via C/S for decels. Infant was born at 25 [**2-5**] wks. See Neonatology Note above for maternal history. Infant showed no respiratory effort at birth and lowest HR noted was 50, increased to 60+ with PPV. Infant was then intubated and a single dose of epinephrine was given via the ET tube - HR then improved to the 120s, skin color improved to pink. Apgars were 2/6/7. Signiicant bruising and swelling of head and neck noted, eyes too are puffy and bruised and unsure if lids are still fused. In the NICU infant was placed on an open warmer with initial temp of 95.9 rectal - warmed quickly on warmer and under heating lights to 98.4 axillary. Infant was placed on conventional vent with intial settings of 24/5 BR 30 and received first dose of surf. Couple of gases were done and have weaned to current settings of 24/5 BR 22 (see flow sheet for values) FIO2 need has been ~ 25-60%. Lung sounds remain coarse. HR mostly 160s, no murmur heard, pulses WNL. Initial B/Ps per UAC were [**Last Name (un) 1627**] in the mid 20s - received a 10cc/k/NS bolus X 1 - b/ps have been stable with means 26+. CBC and blood cultures were drawn and sent - initial doses of Gent and Ampicillin given. HCt 39.8, plts 207, WBC 15.2 and diff was 34/3/40. Initial d-stick was 37 - was started on D10W at 80cc/k peripherally and was given a D10W bolus - f/u d-sticks were 48 and 48. A DLUVC and UAC were placed - currently fluids are 1/2 NS via the UAC and D10W via the UVC (with heparin added to both lines). Infant has voided X 2, passed small amt meconium X 2. Anterior fontanelle is soft, full and "boggy". Infant's eyes remain ?fused (versus very swollen). Infant showing minimal movement of his extremities, no grimace noted. Parents were in to visit at the bedside - they were updated at the bedside by MD [**Doctor Last Name **] and were appr. teary-eyed and asked appr. quesitons A: 25 [**2-5**] week infant, with extreme bruising and swelling of head and neck. Respiraotry distress - was intubated and surf given. R/O sepsis. P: Moniter resp status closely and wean vent as possible. Moniter neurostatus/neuro exam closely and plan made for a head U/S to be done tomorrow (Tuesday). Follow blood suagr as needed and paln made to check lytes and bili at 12 hrs of life. Keep parents supported and updated on plan of care.

Overall Neutral Note

NPNOte: #1. Remains orally intubated with vent support, rate 27/mt, 21/5, fio2 28-43%, BBS coarse,mild intercostal/ subcostal retractions present,Abg at 8pm 7.27/60/48/20/-8, NaHco3 iv given as ordered. ABG's repeated,(please refer flow sheet) vent settings were changed, latest ABG on current settings 7.27/53/75/25/-2.At times rides the vent with desats to low 80's needed increase in 02. Et suctioned for tan colored secretions and oral cloudy mod secretions. No B's or spells noted. Fio2 requirement increased with care.A; labile with o2. P; continue resp support as needed. #2.No murmur, ruddy with mildly jaundiced, hyperactive precordium. Bp means maintained 32-35,max dopamine was 5mcg/kg/minute, currently on 3Mcg/kg/minute infusing at PICC line. P; continue to maintain means 32-35. #3.Todays weight=1020gms, up 10gms, generalized edema +,NPO TF=80cc/kg/day, was on 100cc/kg/day was decreased by NNP, D10pn at 50cc/kg infusing at left arm PICCline, [**1-12**] n.saline with Hep at 25cc/kg infusing at UA line, and Dopamine at ~5cc/kg at PIcc line, D'stix 137-120-82. Hep lock in situ.Hypoactive bowel sounds, abd round, voided 6.6cc/kg/hr, for last 12hrs. no stool yet.lytes at 10.20pm 138/5.4/107/20/16, NNp aware.lytes will be repeated at ~6am today. P; continue current nut. plan/ NPO. #4. Blood culture results pending, on Amp+ gent given as ordered. Picc line dressing changed by NNP for slight oozing of blood. #5. mIldly jaundiced, bili 4.4/0.3/4.1 at 10.20pm. Infant is under single phototheraphy eye shield on. #6. alert and active with care, moving all extremities, brings hands to face,temp stable on a warmer bed,nested in sheepskin, Aquphor applied.skin abrasion, bruise noted on chest and extremities, care given.A; AGA P; continue dev support. #7. Parents visited,asking app questions, for family meeting today.A; loving parents. P; continue update and teaching.

Overall Neutral Note

NPN 0700-1530 1. Recieved infant intubated on hi fi with settings of MAP 9, delta P 16. Gas obtained at 1300, and MAP increased to 10. FiO2 32-45% all am, yet increased required increase to 60-86% at 1pm at which point MAP increased. Awaiting CXR. LS coarse, with SC/IC retractions. COntinue to monitor resp status, wean O2 as tolerated. 2. No murmur heard. HR 140-150's. Weak pulses, good cap refill. Infant ruddy. Unable to obtain cuff BP, means via UAC 16-18. With increased FiO2 requirements, NS bolus given at 1410 and dopamine started at 5.5mcg/kg/min. COntinue to monitor. 3. TF increased to 170cc/kg/day at 1430 for Na of 151. UAC with sterile water and 7.7meq sodium acetate running at 50cc/kg/day. DUVC has D10 with 0.5u hep per cc at 70cc/kg/day via primary line and PN D5 with hep infusing at 50cc/kg. D sticks 71, 82 thus far this shift. Lytes obtained on Q4 hour schedule- see carevue for details. VOiding with .6cc/kg/hr output in 8 hours. COntinue to monitor lytes, D stick. 4. Infant nested in sheepskin on open warmer, with tent. Warmer temp increased this am for temp of 97.5, stable since then. Fentanyl given x1, prior to care and repositioning. Tolerated care well. Moving all extremities. COntinue to promote growth and development. 5. Parents in this AM, updated on plan of care. Parents asking appropriate questions, loving and attentive. COntinue to update, educate and support parents. 6. Infant remains on amp and gent, no s/s of infection. CBC to be drawn in AM. COntinue to monitor. 7. Infant increased to double phototherapy this AM. Bili 2.8/0.3 this AM. Eye shields in place. Bili to be checked in AM.

Overall Neutral Note

Nursing Progress Note #1-O/A- Received infant on HFOV MAP=8, Amp=19. Infant weaned to MAP=7, Amp=15 for good ABG's. FIO2 23-32% so far this shift. No resp distress. CXR done, well expanded. P- Cont to assess for Resp needs. #2-O/A- No audible murmur. S/p 2 courses of indocin. Plans for echo tomorrow. Cont on Dopamine to keep BP means 23-30. PLT count 94 this am, Receiving PLT transfusion. Also ordered to received PRBC's and FFP. P- Cont to assess for CV/heme needs. #3-O/A- TF increased to 200cc/kg/d. UAC with 1/2 Na Acetate with 1/2unit of Heparin/cc. DLUVC with TPN D9 and IL via primary port. TPN D9, D12.5 with 5mEq KCl and 1/2unit Heparin/cc and Dopamine (30mg/50ml D5W) via Secondary port. KCl increased in IVF due to K of 2.6 this am. Plans to check level of K this evening. Dsticks wnl. Voiding, no stool. P- Cont to assess for FEN needs. #4-O/A- Baby Girl [**Known lastname 256**] #2 cont to be active and alert with cares. Temp stable on warmer with tent. Infant nested in sheepskin. Gel pillow under head only. Fentanyl given as needed for comfort. P- Cont to assess for G&D needs. #5-O/[**Name (NI) 120**] Mom in to visit with udpates given. Loving and involved. P- Cont to enc parental calls and visits. #6-O/A- Cont on day [**7-12**] of Amp/Gent. Cont on day 2/? of Vanco. Awaiting negative blood cx to determine length of course of Vanco. No current s/s of infection. P- Cont to assess for s/s of sepsis. #7-O/A- Cont under Neoblue phototx. Bili this am 2.5,0.6. Cont to assess for Hyperbilirubinemia. See flowsheet for further details.

Overall Neutral Note

NPN 1900-0700 #1: O: Infant continues on HFOV, MAP 7 deltaP 16. FiO2 23-32%. ABG this shift 7.34/47/55/26/0, no changes made. LS c/= with mild ic/sc retractions. Sx with cares for scant to small cloudy from ETT and mouth. Infant continues to be labile, but no spells. Continues on vitA. A: Stable on HFOV. P: Continue to monitor. #2: O: No audible murmur. HR 140's-150's. Infant is ruddy/pink, well perfused. MAPs via UAC have been 24-31 this shift. Cuff BP 47/37 with a mean of 41. Infant has been off dopamine since yesterday. Crit this shift 38. B.O. 3.2cc. P: Continue to monitor, keep MAP >23. #3: O: Current weight 400g (+50g). Infant is NPO. TF 160cc/kg/day still being based on birthweight of 380g. Infant has a UAC with 0.5NS with 0.5U heparin infusing at 0.8cc/hr. Infant also has a DL UVC. through the primary port PN D9 is infusing at 0.7cc/hr with IL piggybacked in at 0.2cc/hr. Through the secondary port D5 with 0.5U heparin is infusing at 0.8cc/hr. Abdomen soft and flat, girth 14cm. U.O. 3.7cc/kg/hr this shift. No stool. Dsticks 104 and 111. Electrolytes with BUN and creatnine sent this shift. See laboratory for results. P: Continue to monitor I&O, dsticks and electrolytes. #4: O: Temp stable on servo warmer under tent. Infant is alert and active with cares. Brings hands to face. Recieved PRN Fentnyl x3 for comfort. Remains nested in sheepskin with gel pillow. A: AGA. P: Continue to support growth and development. #5: O: Mom in for first set of cares. Loving and appropriate with infant. P: Continue to support parents in the care of their infant. #6: O: Infant is currently day [**11-11**] of Amp and Gent and day [**6-4**] of Vanco. CBC sent this shift not shifted. Last shifted CBC was [**8-27**]. Last BC from [**8-25**] negative. P: Continue to give abx as ordered. #7: O: Infant continues under neoblue mini. Bili sent this shift, results pending. P: Continue to monitor.

Overall Neutral Note

Nursing Progress Note #1-O/A- Received infant on HFOV. Infants MAP and Amplitude has been increased and decreased as needed for ABG's. CXR done showing ETT deep and atelectasis on one side. Infant repositioned with tension on ETT. Infant showed improvement with better FIO2 and ABG's. Infant currently on HFOV MAP=10, Amplitude=20. FIO2 currently 21%. Has been 21-100% today(positional). Scant secretions when suctioned by RT at position change(flip). P- Cont to assess for Resp needs. #2-O/A- No audible murmur. Infants HR wnl. Mean BP kept>23 with Dopamine, currently at 9mcg/kg/min. Started on Indocin, received first dose at 8am. PLT COUNT down to 98 from 155. Infant ordered for Platelets(currently infusing and FFP. No CV distress. P- Cont to assess for CV needs. #3-O/A- TF=180cc/kg/d. UAC has [**1-31**] Na Acetate w 1/2unit of hep/cc. DLUVC has TPN D7.5 via Primay and Secondary ports. D5W w/[**1-31**] unit Heparin /cc and Dopamine(60mg in 50D5W) piggybacked in Secondary port. Abd exam benign. Voiding large amounts. MD aware. Lytes to be drawn q8hrs. Na remains high last level=149. MD aware. No sodium in TPN. Dsticks wnl. P- Cont to assess for FEN needs. #4-O/A- Baby Girl [**Known lastname 256**] #2 remains active and alert with cares. Infant opens eyes and moves around. Grasp reflex noted during cares. Nested in sheepskin with boundries and gel cushion for comfort. Temp stable on warmer under clear plastic tent. P- Cont to assess for G&D needs. #5-O/A- Parents in to visit with updates given. Difficult day for parents. Twin #1 decompensated this morning while they were at bedside. Infant was "coded" for about 30 min. Infant did not survive despite everything that was done. Chaplan called and was present for prayers. Social work was called for support as well. Parents expressed their wishes for both their babies and also mentioned that they are private people. They had some private time with the deceased baby. They returned to Mom's hospital room. They have note been

Overall Negative Note

Nursing Progress Note #1-O/A- Received infant on HFO MAP=8, Amp=15. Infant remains on those settings. FIO2 23-30% so far this shift. No resp distress. No desats. Good ABG this afternoon. P- Cont to assess for Resp needs. #2-O/A- No audible murmur. Cont on Indocin for mod PDA on echo. Cont on Dopamine to keep Mean BP 23-30. Current blood out 2.24ml. Plans for CBCw/diff in am. P- Cont to assess for CV needs. #3-O/A- TF=180cc/kg/d. UAC with 1/2 NaAcetate with 1/2unit of heparin/cc. DLUVC primary port with TPN D9 and IL. Secondary port with TPN D9, D12.5 w/heparin and Dopamine(30mg in 50ccD5W). Infant had Dstick of 45 today, was treated with a D10W bolus and IVF Dextrose was increased from D10 to D12.5. Subsequent dsticks stable. Abd exam benign. Remains NPO. Voiding, no stool. Plans for lytes, BUN and Cr in am. P- Cont to assess for FEN needs. #4-O/A- Baby girl [**Known lastname 256**] #2 cont to be active and alert with cares. Fentanyl given X2 for comfort. Temp stable on warmer under tent. Nested in sheepskin. Gel cushion under head only. P- Cont to assess for G&D needs. #5-O/A- Parents in to visit with updates given. Mom was discharged from hospital today. Parents stated that they will be staying at the [**First Name8 (NamePattern2) 3159**] [**Last Name (NamePattern1) 3162**] on [**Location (un) 3167**] St. in the [**Hospital1 **]. Parents loving and appropriate. P- Cont to enc parental calls and visits. #6-O/A- Cont on Amp/Gent day [**6-4**]. On day 1 of Vanco. No current s/s of infection. P- Cont to assess for s/s of sepsis. #7-O/A- Remains under Neoblue phototx. Plans to check bili in am. P- Cont to assess for Hyperbilirubinemia. See flowsheet for further details.

Overall Neutral Note

NPN Days #1 Resp: Infant remains intubated on HFOV, MAP 6 AMP 15, Fi02 26-38%. Spontaneous RR 20-30's, LS c/=, IC/SC retrac. Sxn'd X1, no secretions noted, small cloudy secretions orally. Cont Vit A. ABG drawn this afternoon (see labs), bicarb given for acidosis. P: Cont to monitor resp status, will repeat ABG 1 hour after bicarb finishes. #2 CV: No murmur appreciated, 150-170's, infant is pink to ruddy, well perfused. Brisk refill, +PPP. BP MAPs mostly ranging 23-34, however infant had brief period of time this afternoon with drop in BP, requiring increased Dopa to 20mcg/kg. Currently Dopa gtt running at 12mcg/kg/min. Infant received first alloquot of PRBCs this afternoon, will transfuse second alloquot this evening. P: Cont to monitor CV status, titrate Dopa to goal MAPs of 23-30, will admin PRBCs this eve. #3 FEN: TF=150cc/kg/day, infant cont to be NPO. Currently [** 1956**] infusing 1/2NS with 1/2U Hep/cc, line to be d/c'd this eve. DL UVC infusing PND5 with Hep, IL, D10W with Hep, and Dopa gtt without diff. Dstick 92. Abd benign, soft, flat, AG 13.5, hypoactive BS noted. Uop 4.2cc/kg/hr, no stool. P: Cont to monitor FEN status, plan to d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1956**], [**First Name3 (LF) **] attempt PICC line tonight-o/w cont with DL UVC. #4 G&D: Temp stable on servowarmer, nested on sheepskin with gel pillow. Alert and active with cares, MAE, opens eyes, enjoys her pacifier, AFSF. Infant appears comfortable, given Fent prn. P: Cont to monitor and support G&D. #5 Parents: mom in a couple of times t/o shift, updated by this RN. Asking appropriate questions, taking pictures, very loving towards infant. P: Cont to encourage parental calls and visits. #6 ID: Temp stable on warmer, infant is alert and active. Cont Vanco D6/7, Amp and Gent D11/14. P: Cont to monitor for sx of sepsis, finish abx courses. #7 Bili: Neoblue d/c'd this AM. P: Will f.u with bili levels Sun AM. See flowsheet for further details.

Overall Neutral Note

Nursing Progress Note: #1 - RESP: Remains on HiFi ventilator - Delta p 16 Map of 8. FIO2 Today 23-30%. Lungs sounds diminished bilaterally. Mild int/sub retractions. Suctioned for minimal amt of secretions oral and tube. Art gas this am - 7.31/50/46/26/-1. No changes made at that time. Plan to recheck this evening @1700pm. CXR planned for [**Doctor First Name 153**] am. #2 - CV: No murmur heard. HR (140-160). Pink and well perfused. Remains on Dopamine 30mg in 50cc's D5W. Mostly 5mcqs today. Early in the shift had top off at 14mcqs briefly. MAPs usually 23-29. Pulse pressures [**5-8**]. Pulses normal. Echo done this afternoon. Results pending. Transfused with first alloquot of PRBC this afternoon. Tolerated well. Plan to start 2nd alloquot this evening. #3 - FEN: NPO. TF remain at 200cc/kilo. Plan to decrease to 180cc/kilo at ~1800pm When change PN/IVF. UA and DLUVC infusing without difficutly. Dstick this afternoon 87. Abdomin soft and flat. Girth 12cm. Hypoactive BS. Voiding. No stool thus far. Lytes to be drawn at 1700pm and again in am with Bun//Creat. #4 - G&D: Temps stable on warmer. Eyes open. Alert and active with cares. MAE. TUrned and repostioned with cares. HUS today - WNL per attending. Skin in good condition. No breakdown. Aquaphor applied. Fent used PRN for stress. Managaged well throughout the day. #5 - PARENTS: Lovely warm parents. Mom in several times today. Updated at the bedside. Father up for family meeting. Teary eyed at times. Signed consent for LP. Mom being discharged [**Doctor First Name 153**]. Staying at local hotel. #6 - Sepsis: Blood cultures neg to date. Day [**5-5**] antibiotics - amp and gent. Repeat Gent peak to be drawn at 1700pm. LP consent signed. #7 - BILI: Remains under neoblue (mini). Voiding. No stooling. NPO. Check bili in am.

Overall Neutral Note

Nursing NICU Note continued #5. Parents O: Mom in to visit this am. She was updated at bedside on pt's current status and daily plan of care. Mom asking appropriate questions. A: Family appears loving and invested. P: Continue to update, support and educate. Social work to follow. #6. Sepsis O: Pt. is alert, active and acting appropriate w/ cares. Temps stable on an open warmer. Today is Day #7/14 days of IV Amp+Gent, Day #[**3-7**] of IV Vanco. Last blood cult -to date. A: Sepsis P: Continue to monitor for s/s of sepsis. Continue w/ IV Abx per schedule. Plan to check CBC in am. #7. Hyperbilirubinemia O: Pt. remains ruddy, warm. She is under Neo-blue mini. A: stable P: Continue to monitor. Plan to check [**Female First Name (un) 531**] in am.

Overall Neutral Note

NPN 1900-0700 1. RESP: Infant [**Last Name (un) 229**] on hifi vent with Map 7, delta-p 18. FiO2 up slightly to 40-57% this shift. ABG at 0300 was 7.36/55/45/32/3. No vent changes made at this time. Lung sounds are coarse to clear. Baseline retractions. No spells or significant desats noted so far this shift. Will monitor closely. 2. C/V: No murmur heard but mod PDA noted per echo report. Infant is receiving her 3rd coarse of Indocin. Infant remains on Dopamine gtt which has been 19mcg/kg for most of this shift to maintain BP means 23-30. She is ruddy and well-perfused with brisk cap refill. Total blood out since last blood transfusion is 1.5cc. Will monitor closely and waen dopa as tolerated. 3. F&N: TF remain at 180cc/k. UAC has Na Acetate with hep, DLUVC has PND10 with IL, D10W and dopa gtt infusing well. Lytes this am are 134/5.2/98/29. D/S at 0300 was 216. D10W infusion changed to D5W. D/S at 0500 was 237. PN rate was changed from 82cc/k/d to 62cc/k/d and D5W infusion increased. Will follow up D/S later this am. Abd is soft and flat with hypoactive BS. U/O 6 cc/k/h. No stool noted. Weight up 30 grams to 400grams. 4. DEV: Baby girl [**Known lastname 256**] 2 is active and alert during her cares. Fentanyl given X 4 for stress related to hifi vent and to help her tolerate cares. She moves all extremities and open her eyes. She is nested on sheepskin on servo-radiant warmer and gel pillow with tent covering her. She has a small blister noted on her left thigh. Umbi appears moist. 5. PAR: Parents in to visit X1. They asked appropriate questions and spoke lovingly to their daughter. They have not decided on a name for the baby. 6. [**Month (only) 375**]: Today is day [**9-11**] of Ampi and Gent and day [**4-4**] of Vancomycin. Blood culture from the 28th is still negative to date. Will monitor closely and continue antibiotics as ordered. 7. BILI: Infant remains under neoblue mini. Bili this am 2.1/0.7/1.4. Will monitor.

Overall Neutral Note

NPN 1900-0700 1. [**Month (only) 375**]: Infant continues on Ampi and Gent. Blood cultures pending. Will monitor results and continue abx as ordered. 2. RESP: Infant received on SIMV 18/6 X30. PEEP decreased to 5. ABG at 0300 was 7.35/35/89/20/-5. [**First Name9 (NamePattern2) 63**] [**Doctor Last Name 64**] aware and vent weaned to 16/5 X28. FiO2 21%. No spontaneous resps noted. Rest rate 28-30. No retractions noted. Lung sounds are clear. Sxn orally for small to large thick white secretions and mod white via ETT. No spells or desats noted. Follow up blood gas to be done later this morning. Will monitor closely. 3. NEURO: [**Known lastname **] remains unarousable and profoundly hypotonic with no spontaneous movements witnessed by this RN. Dad reported a leg jerk movement noted X1. Hands remain clenched and small roll placed in her palms to prevent contractures. Passive ROM to extremities done with cares. Awaiting EEG results. 4. F&N: TF remain at 100cc/k/d. UAs has 1/2 NS infusing well. DLUVC has D10W in primary port and PND10W in secondary port infusing well. D/S 109. 24 hour lytes 143/4.1/111/18. [**First Name9 (NamePattern2) 63**] [**Doctor Last Name 64**] aware. This mornings labs are pending. Abd flat. No audible bowel sounds. A/G stable. U/O 1.8cc/k/h. No stool noted. No weight change. 5. DEV: [**Known lastname **] remains nested on sheepskin on servo-radiant warmer with gel pillow. Temp stable. Chromosomes to be sent later this am. 6. PAR: Dad in with many family members and both parents in to visit with [**Known lastname 4420**] siblings. They all spoke lovingly to [**Known lastname **] and asked appropriate questions. Dad made this RN aware of the leg jerk movements. He stated, "I am going to hold on to hope. I think she will make it. She is very strong." Will continue to support family.

Overall Neutral Note

Nursing Progress Note: RESP: REmains on SMIV 18/6 rate of 30. FIO2 21%. RR (30). No spontaneous resp effort. Coarse to clear. Suctioned once for no secretions. No retractions. No bradys or desats. Last arterial gas at 1700 - 7.29/47/80/24/-3. No changes made today. CV: HR - 133-141. Little variability. Pink/ruddy well perfused. No murmur. Cardiac echo - done this afternoon - PFO, sm PDA, subnormal left ventricular cavity. BP MAPs stable 36-55. 59/44 51. Blood out 5.2cc's. DLUVC noted to be in left atrium - per echo - NNP pulled line back this evening. ID: Remains on 48 hour rule out. Amp and gent continue at this time. Blood culture neg to date. CBC repeated this am - WBC - 10.5, HCT 55.5, PLT 389, N - 51, B - 0, L - 29. FEN: BW - 1050grams. TF at 100cc/kilo/day = 4.4cc/hour. Currently has UA and DLUVC lines. UA - 1/2 NS with 1/2 unit Hep/cc at 1 cc/hour. DLUVC - primary port with D10W with 1/2 unit heparin at 1.2cc hour. Secondary port with TPN - D10W and heparin at 50cc/kilo - 2.2 cc/hour. Abdomin soft and flat. No BS. Girth 17.5 - 18cm. Voided 1.7cc/kilo for this 12 hour shift. No stool since delivery room. Dsticks today 110, 122. NEURO: Remains unarousable, profoundly hypotonic, no spontaneous movement. No reflexes, Pupils fixed and dilated, minimal to no variability in HR/RR. Neuro consulted. HUS done - normal. EEG done - awaiting final report. [**Month (only) 103**] need MRI. DEV: Temps stable on open warmer. Turned and repositioned with cares. PAssive ROM done with each cares. Mouth care done at each cares. Nested in sheepskin/water pillow. Genetics consulted due to mild dysmorphic features - short tip of nose - pointed up, mildly low set ears, set back. Right [**1-27**] toes crossing over. Claw flexed hands. REquested checking chromosomes. PARENTS: Mom and Dad in throughout the day. updated at the bedside. Updated by Neuro earlier. Awaiting eeg results. Loving family. Expressing difficulty about having to talk to their older children about [**Known lastname **].

Overall Neutral Note

8 Jaundice Nursing Progress Note: #2 - RESP: REmains on IMV settings of 19/5 rate of 30. Weaned rate from 35 at 1500pm for art gas of 7.51, 25, 105, 21, 0. FIO2 21%. RR (30). No spontaneous resp effort. Lungs clear and equal. No retractions. No spells. #3 - NEURo: MRI of head and spine done. Poor prognosis. Believed to be a hypoxic ischemic event possibly metabolic related effecting the brain and spine. REmains unresponsive with no spontaneous movement noted. EEG yesterday showed absence of cortical activity, wide spread severe encephalopathy, and no seizure activity. Neuro and genetics are following. Chromosomes are pending. #4 - FEN: TF remain at 100cc/kilo/day. NPO. Continues with UAC and DLUVC. Remains on TPN and lipids as ordered. Dstick 97. Abdomin soft and flat. Girth 18cm. No BS. Voided 2.4cc/kilo for this 12 hours. No stool since birth. Lytes and bili in am. #5 - DEV: TEmps stable on warmer. Did get cold when at MRI test - was quickly warmed with additional lights when arrivign back to the floor. Placed on lillypad mattress for pressure points this afternoon. Continue to provide passive ROM q 2hours. #6 - PARENTS: Mom and Dad in throughout the day. Brought 8 and 10 year old sibling in this afternoon. Updated at the bedside. ATtending, SW and RN spoke with parents this evening regarding MRI results. Parents have been preparing for this devastating news for the last few days. #7 - CV: No murmur heard today. Pink and well perfused. HR (120-140). Cuff BP - 70/43 53. MAPS 44-53. Mild generalized edema. #8 - Jaundice: Started single phototherapy this am for bili of 5.5/0.4. Recheck bili in am. Glasses on. Voiding. No stool since birth. NPO still. REVISIONS TO PATHWAY: 8 Jaundice; added Start date: [**2165-9-13**]

Overall Neutral Note

NPN 1900-0700 2. RESP: Infant remains on SIMV 16/5 X30. FiO2 28-33%, up to 40% after a desat to 83% after her cares. Lung sounds are clear. No spontaneous breaths and no retractions noted. No spells noted. Sxn for mod white via mouth and ETT Q 4 hours. No spells noted. 3. NEURO: Infant remains unresponsive with no spontaneous movement and pupils are fixed and dilated. Parents made aware of EEG results by Dr. [**Last Name (STitle) **]. MRI to be done later today. 4. F&N: NPO. TF 100cc/k/d. UAC has 1/2NS with hep infusing well. DLUVC has PND8 with IL infusing well. Abd soft and flat. Bowel sounds are hypoactive. A/G stable. No spits noted. U/O 2.3cc/k/h. No stool noted. Weight loss 10 grams. 5. DEV: [**Known lastname **] is nested on sheepskin with gel pillow. Passive ROM done on all extremities with each set of cares. Temp stable on aervo-warmer. Skin intact but infant is edematous. She is slightly jaundiced and bili level to be drawn later this am. 6. PAR: Parents in to visit with infant's siblings and other friends and family members. They ask approrpiate questions and speak lovingly to [**Known lastname **]. 7. C/V: Murmur heard at 2400. HR 139-142. She is well-perfused. BP 61/31 X42 and UAC means WNL. She is edematous with brisk cap refill. EKG to be done this morning.

Overall Neutral Note

NICU NSG ADMIT NOTE 28 [**1-2**] week female admitted to NICU from L&D for prematurity, r/o neurologic abnormality. Please see above MD note for detailed hx. Infant arrived to NICU via heated transport isolette, intubated being ventilated by Neopuff. Placed on radiant warmer with monitors on. 2.5 ETT inserted in OR replaced with 3.0 ETT on arrival in NICU. Received 1st dose survanta and placed on SIMV. UAC/UVC placed by NNP and CXR confirmed placements of ETT and lines. CBC and Blood Cx obtained and sent. Baby cares given. Reivew by system: Currently on vent settings 21/6 x40. No spontaneous resp effort seen. RR consistant with vent breaths., LS coarse. Last ABG 7.45/32 (on PIP of 24 and rate of 46 at that time). No mumrur. Color pink. Well perfused. Cuff pressures 60's/30's. UAC means 33-37. BW 1050g. NPO. TF 100cc/k/d. UAC with 1/2NS with 1/2u hep/cc. DLUVC with primary port D10W and 1/2u hep/cc and secondary port Starter PND10 at 50cc/k/d. DS 70/62/104 respectively. Infnat has voided 1cc. No stool. Abd soft and flat. Hypoactive BS. BUN, Cr and LFTs per lab report sheets. Temps stable on radiant warmer. No tone--somewhat contracted extremities. No grimace. No repsonse to stim/pain (Vit K injection). No moro. Neuro has been in to consult. Plan for HUS, EEG and ? MRI tomorrow. CBC and Blood Cx obtained and sent. No left shift. 1st doses ampi and gent given. Parens have been in and updated by Attending [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] on infant's condition. Parents teary-eyed at bedside. Dad brought in 10yo and 8yo siblings to meet infant. They will need SW involvement in am.

Overall Neutral Note

Nursing NICU Note Cont. 6 Alt. in CV status. 3. F/N. O/Remains NPO. TF decreased to 60ml/k/d. TPN D10 w/ hep now running at approx 34ml/k/d and IVF D10 w/ hep running at approx 13ml/k/d via intact DLUVC. 1/2NS with hep running at 1ml/hr via intact UAC. Has voided 6ml this shift (Attending aware). No stool passed. Please refer to flowsheet for examinations of pt and dstick results. A/ Generalized edema still present, but apperas less. Alt. in F/N. P/[**Last Name (un) 1225**] I/O as ordered. Cont. to monitor. 4. G/D. O/Morphine drip started at 10mcg/k/hour (concentration 5mg/50ml D10W). Pt also recieved a few morphine bolus doses prior to procedures. Pt occasionally opening her eyes. Appears to be sleeping when left undisturbed. Adjusting servo control for varying temps [**Name8 (MD) 1226**] NNP aware. Chromosomal analysis sent. A/Pain appears controled. P/Cont. to monitor for evidence of discomfort. Cont. to monitor for temp instability. Cont. to support pt's growth and dev. needs. 5. [**Name8 (MD) 5**]. O/Mother called this shift and both mother and father in to visit pt. This nurse [**First Name (Titles) 55**] [**Last Name (Titles) **]. [**Last Name (Titles) 5**] stated that they feel up to date on pt's status. Mother and father touched pt gently on hands and face and spoke softly to her. A/[**Last Name (Titles) 5**] are involved in pt's care. P/Cont. to support and educate [**Last Name (Titles) **]. 6. CV. O/Please refer to above notes for ECHO results. Skin becoming pinker. Normal pulses. Brisk cap refill noted. Team is aware of BP results from this shift: No change in plan of care made thus far. Pt receiving 1st alloquot of PRBC as ordered. A/Hypotension noted and reported. CV status appears stable at this time. p/Cont. to monitor BP. Cont. to monitor tolerance to PRBC transfusion. 1. Blood sent for parvovirus. Urine bag placed to send for CMV. REVISIONS TO PATHWAY: 6 Alt. in CV status.; added Start date: [**2133-8-13**]

Overall Neutral Note

NPN Days #1 ID: Temp stable, infant is acting AGA. Cont Amp, Gent, and Oxacillin for r/o sepsis. Bld cxs NTD. P: Cont abx, f/u with cxs, monitor for sx of sepsis. #2 Resp: Received on 19/6 X 22, rate increased to 25 following VBG (see labs). Fi02 33-40%,breathing 20-40's, LS coarse, IC/SC retrac. Sxn with cares for mod cloudy secretions. No spells, occ desats requiring 100% Fi02, mostly surrounding caretimes. Began vit A this afternoon. P: Cont to monitor resp status. #3 FEN: TF=170cc/kg/day, infant receiving D5W with 1/2UHep/cc, PND5, and Dopa gtt via DL UVC, infusing without diff. PAL infusing NaAcetate with 1U Hep/cc. Cont with Q4H lytes (see labs), Dsticks 150, 109. Abd soft, flat, no audible BS, AG 15.5. Uop so far this shift 1.5cc/kg/hr, no stool. P: Cont to monitor FEN status, Q4H lytes #4 CV: No murmur, 150-170's, infant appears pink to sl jaundiced, well perfused. Brisk cap refill, equal pulses, quiet precordium. TBO 4.2cc, BP MAPs from PAL 19-25. Dopa cont at 10mcg/kg at this time. P: Cont to monitor CV status, will follow clinically to adjust Dopa, unable to get cuff BPs at this time. #5 G&D: Temp stable on servowarmer, nested on sheepskin with gel pillow. Alert and active with cares, opens her eyes, grimaces with repositioning. Infant settles quickly, sleeps well, appears comfortable. HUS done this AM-WNL. Infant's skin is grossly intact, appears gelatinous and shiny. Erythema surrounds umbi and is patchy t/o trunk. Some bruising noted to the extremities, and mepital dsg to L foot is intact. Aquaphor applied with cares. P: Cont to monitor and support G&D, monitor for pain, monitor skin integrity. #6 Parents: Parents in this AM, updated at the bedside by this RN and NNP. Asking appropriate questions, very loving towards infant. Observed infant's caretime, and provided hand containment. P: Cont to encourage parental calls and visits. #7 Bili: Cont double phototherapy for hyperbili. P: Cont to f/u with levels, cont phototherapy. See flowsheet for further details.

Overall Neutral Note

Procedure Note: Umbilical Venous catheter adjustment UVC on x-ray shown well into heart. UVC withdrawn 1 cm without incident. Repeat x-ray planned.

Overall Neutral Note